DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.
Date of interview: 9th April 2020
Number of confirmed cases at time of interview: 395030
Number of deaths at time of interview: 12740
Population: 327.2.million people
This week I am interviewing Dr Jay W. Lee, who is a family physician and Chief Medical Officer in a federally-qualified community health centre in Orange County (aka “The OC”). Interestingly, the OC, an area with a mixed demographic of affluence sitting alongside deep pockets of deprivation, doesn’t have a county hospital despite being the 6th biggest county in the U.S. When I speak to Jay, he’s about a month in to his new job and they are deep in contingency-building phase where the upward curve hasn’t been hit yet – that agonising calm before the storm. I would probably say that he was thrown into the deep end and call this a baptism of fire.
Like many clinics across the world, they have noticed a reduction of people coming in which is a concern that many family doctors and emergency doctors worldwide have shared. Jay suspects that they are either sick and gone to hospital or sick and afraid to leave their home or sheltered and can’t leave home anyway. Whatever the reason, there is a population who are suffering in silence in the community. In the UK, we have had to have a public health campaign to explain to everyone that both community clinics and hospital emergency departments are still open and should be accessed if required. In Jay’s, clinic, they have moved online to tele-consultations about three weeks ago and they seem to be going well. There might be a slight worry that the clinic might lose money but thankfully an online consultation is being paid at the same rate as face-to-face consultations. Coming from a country (UK) where primary care is state-funded and paid per patient, I am always struck by countries where they are paid for performance and how this virus can affect different aspects of clinic logistics. I’ve also noticed this when talking to Phoebe from Australia where they are unable to charge co-payments from tele-consultations which would lead to a reduction in clinic income. Jay mentions that the federal government has sent out cheques to community health centres to allow them to meet their payroll due to the reliance on volume of visits (i.e. patients coming in) for payment. However, this has not yet been extended to the private practices.
Jay has to explain to me how his clinic is funded which is a mix as they receive a mix of patients. Click here if you want to read my previous attempt to deep-dive into the American healthcare system. Essentially, there are many stakeholders in American healthcare and patients are covered in many different ways. For the majority who are insured, rates for consultations are negotiated locally with the federal government which is based on a variety of factors (including if there is a regional shortage of doctors) but the clinic have to show that they are seeing enough patients to warrant this rate. For those who qualify for Medicaid (i.e. the more destitute), the clinic is paid per capita. For those who are uninsured and not qualifying for Medicaid, there is a sliding scale that the patient has to pay relative to how close they are to the poverty line. This is assessed by a federal agency through a needs assessment and seems to be a rather well-oiled process. I’ve always had my concerns of being in a country without universal healthcare in a public health emergency but it seems like Jay’s clinic are doing the best they can to make sure that everyone receives care. He also points out that since the Affordable Care Act, the number of uninsured has dropped from 70% to 30% (these are the stats from the clinic he was previously working at).
Nasophyaryngeal swabs are available for everyone but due to the limited supplies, they are doing targeted testing. Although touted to have a 48-hour turnaround, the reality is 7-12 days in some cases. If you have fever, difficulty breathing and a cough, you can attend for kerbside testing where a physician, a medical assistant and security will meet you in full Personal Protection Equipment (PPE) to swab your oropharynx. Jay says that they have a lot of PPE because they have been building their capacity for emergency preparedness but the burn rate is so quick that they are having to work hard to replenish stocks. They have recently started a collaboration with the Californian Academy of Family Physicians where a google spreadsheet was started by their policy director and his wife to connect health centres with donors which I think is a brilliant idea. We have similar initiatives in the UK which are locally managed and I am so proud of all those community members who have stepped up to donate what they can.
So let’s talk PPE. In Jay’s clinic, they are using eye protection, N95 with surgical masks with inbuilt eye protections (i.e. two masks), a gown and double gloving. Let’s compare this to the UK where the guidance is a visor, a single surgical mask, a plastic apron and single layer of gloves. Personally, I feel that we are looking at each other from opposite sides of the WHO guidance on PPE and I can’t help but be amused by the radical differences between the U.S and U.K which reflects the differences in culture – the bold American and the conservative British.
We talk about the medical community and how there is an expectation that we work and put ourselves on the frontline as a moral authority. Jay feels that there is a renewed energy for the physician community to take back healthcare leadership from managers and businessmen. He says that the healthcare system has been fragmented and has favoured profit over efficiency. Although this may historically have been because doctors wanted to do the doctoring and leave the business side of things to others, this has led to a lack of unification and standardisation of healthcare delivery over time. The silver lining here is that, after the immediate pressures of the virus subside, there will be a real push for judicious use of healthcare dollars that make sense medically and not financially. He illustrates this by a concept called the ‘Medical Loss Ratio’ – for every dollar spent, the ratio of how much is spent on medical services and how much is spent on overhead costs such as marketing, profit etc. He feels that the system is not set up to deliver medical care efficiently and this is what is going to change.
There’s one particular thing that I keep wanting to come back to with my conversation I am having with Jay and that is how the clinic is acting as a pillar in the community and not just as a health centre. They have a housing agency for the homeless; rental assistance advice; relationship with local philanthropy; behavioural health unit; substance misuse unit; and a food pantry to give out free packages of food to those in need. Sadly the uptake for the food packages has increased from 200 packages a day to 250 and, on one particular day, 290 were given out. Restaurants which have closed in the lockdown are donating their food to the pantry and local volunteers run it. They use social media and even the muzak on the clinic phone queues to remind that they are here to serve everyone, including undocumented migrants. They are phoning up the most vulnerable including potential domestic violence victims in the co-ordinated outreach calls programme to ask “how are you?” “are you lonely” “do you need help?”. He’s worried that the new rise in unemployment, the rise in homelessness, the food insecurity – the hidden impact of COVID-19 – will lead to a second wave of misery. I genuinely love this because I love the way the clinic is engaging with the community to minimize long-term disruption. I have felt that GP practices are perfectly situated to spread accurate information to patients and to act as leaders in the community during this crisis so I am delighted to see Jay’s clinic take this initiative.
So, how are members of his community finding the public health measures? Being imperial rather than metric, they have a ‘6 feet rule’ (approximately 1.8m) and instead of lockdown they have ‘shelter at home’. I love this term because it has a much more nurturing connotation to the term compared to ‘lockdown’ which we use in the UK which sounds harsh and militarised. Words matter and personally I prefer to use the term ‘physical distancing, social connection’ which is what we need right now. Jay thinks that even it should be ‘social solidarity’ which I also love. He happily reports that people are respecting the rules and there’s only been the occasional story of someone flouting them – such as a surfer who had decided to go surfing but he was arrested mainly because he refused to co-operate with the police. People are allowed to leave the house for essentials and exercise and they have been given a list of businesses that are considered essential and non-essential. In comparison, in the UK, we have had some pretty vague rules and it has been fairly open to interpretation. I do wonder if this has been pre-calculated because, as a nation, we don’t really like being told what to do in the UK and we respond better to social rules and peer pressure. Or is it just bad politics? Who knows?
So what next for Orange County? Jay doesn’t want to commit to an answer until we’re on the other side of the curve. How long will we have ‘shelter in place’? Who will be left standing on the other side? Who has the reserve to take on the patients who survives this? COVID-19 has made us think about our own mortality – both as physicians and also as individuals. People have had to ask themselves whether they were in a vulnerable group and therefore at high risk of dying if contracting the disease and we’ve had to re-evaluate how we feel about being put on the frontline. He’s noticed that COVID-19 has made us all have that conversation with our loved ones about advanced life planning and I’ve also noticed that it has encouraged a lot of us to write wills ‘just in case’. Not only has COVID-19 encouraged us to change the way that we work and pushed primary care into digitalising but it has accelerated many difficult discussions that have been sitting on the shelf.